Violence against Nurses: A Reflection Paper

Mohammad Salem MSc^*
*Correspondence: Mohammad Salem, MSc, India, Email:

Abstract

This paper provides my reflection and examination of a typical incidence that elucidates the challenge of violence against nurses and physicians in the healthcare facilities. Literature records that nurses often come to contact with the outsiders of the cl inic and are at high chances of meeting violence. Hence, it is significant to learn from the past event through a reflection on practice. In my case, I encountered a violence case when I tried to intervene in a case when one of the patient’s visitors came to disagreement with the nurse on duty on how to position a comatose patient. Accordingly, the narrative presented in this article shows my reflection on practice within the confines and guidelines of Gibbs’ model of reflection on practice that runs from the narrative of the event, what was bad, what was good, an evaluation of the event and the action plan. Nevertheless, I noticed that such challenges as violence are inescapable and that I need to inculcate a sober mind and think within the professional boundaries.

Keywords

Violence • Healthcare facilities • Tertiary care • ICU cubicle

Introduction

Various scholars have reported that violence against nurses and physicians has become a common challenge in several hospitals across the globe. For examples, a study conducted by Abualrub and Al Khawaldeh [1] to determine the prevalence violence against nurses at the workplace reported high percentages ranging between 36% and 81%. Moreover, Sofield and Salmond [2] explain that nurses come to frequent and prolonged contact with patients and the family members and visitors thereby making them vulnerable to violence from the outsiders of the healthcare facilities. As a registered nurse, I have encountered the violence within my clinical unit of operation in various instances. Such encounters can easily lead to a prolonged disturbing effect and can adversely affect the healthcare service delivery. A reflection on practice is a significant phenomenon in the healthcare systems since it presents a chance to scrutinize one’s actions and learn from them [3]. In this context, I selected on a typical instance when I encountered violence from a relative of one of the inpatients within clinical unit of practice. I will thus present the reflection accordance to three reflection models; Gibbs’, John’s and Rolfe’s model as a way of empowering self-improvements. Accordingly, this paper will being with the illustration of the violence event which occurred followed by the three common models of reflection on practice in a comparative manner before selecting the best model to use in the reflection on practice.

Narrative of the event

I encountered violence while working in one of the busiest Intensive Care Units of a tertiary care hospital in Abu Dhabi. The setting is a 24-bedded unit for level six critical care patients that are transferred from other hospitals and emergency departments. My role was to provide the necessary safety to such patients as well as other technical support to the bedside nurses whenever they needed it. During my routine tasks on a day shift, an incident happened in the afternoon inside one of the ICU cubicle. I heard loud shouting voices emanating from a specific patient cubicle within the clinic. As the clinic transfer coordinator, I went to find out what was going on. I arrived and found two female nurses and a male visitor quarreling at one another. The nurses narrated to me that the visitor wanted the nurses to allow him to sit the comatose patient at the age of the bed. One nurse was trying to prevent him from sitting the patient while the other was on the floor like she was wrestled until she fell. I tried to intervene by asking the male visitor to let us handle the case sensitively since there were lots of risks involved in forcing the patient to such a posture at the edge of the bed. He became even more agitated and reasoned that the patient was his mother and thus had an equal share in handling her. Nevertheless, I maintained calmness while trying to improvise an amicable solution, by using the Arabic language to make him feel the touch and concern. Eventually, I succeeded in convincing him to leave the room but he pushed me back and started threatening me as I stopped him from repositioning

the patient. I felt greatly disappointed and angered, although I did not show strong negative facial expression against.

Review of the Models of Reflection Practice

Three models are reviewed herein. Gibbs reflective cycle of 1988, Rolfe reflective model of 2001 and John’s model of 1994 are the most commonly cited models of reflection on practice. These models scrutinize the past events and help the victim to analyze their actions and feelings during such events for an improvement. Besides, these models of reflection on practice give the author the chance to examine all their actions and also, the possible initiatives that they could use in such instances.

Gibbsâ?? reflective model

Gibbs’ model revolves around six main stages that are shown in the diagram below.The first stage of Gibbs model, description, gives the illustration of the event and the details of the background information of the case under study. However, Rodrigo express that it does not give a deeper examination of the issues surrounding the event. Within the cycle, description is followed by the expression of the feelings then evaluation of what happened. The feelings indicate the author’s emotional implications from the event. The analysis succeeds the evaluation to give the critical aspects of the incidence before the next action is planned. Gibbs’ model on reflection practice relies on the strength that it deeply dwells on the event, criticism, evaluation and touches on the feelings of the individual [5]. Besides, it gives a cyclic consideration of the incidence. The stages follow each other in a progressive manner that is easy to follow for reflection. However, one major weakness has been pointed out by Barksby et al., [6] who indicate that this model has some repeated steps that makes it unclear for the learners to use properly. This can be related to the evaluation and analysis stage. However, these are both giving an inner scrutiny of the individual’s actions.

Johnâ??s reflective model

John’s reflection model is also commonly applied to the healthcare systems. It starts by describing the case, just as described by the Gibbs’ model. However, according to Dimavo and Kamarsak, the description should cover elaborate areas that explicitly extend beyond the mere activities of the scene. Its description goes further to

the point of looking at the consequences of the author’s actions. Besides, the description brigs in the feelings of the author at this level. Finlay considers the emotional involvement at this stage to be the major advantage of John’s model. After the description is the influential factor around the incident. They examine the contributing factors to the occurrence of the event as well as the alternative approaches to the author’s actions. As Gibbs’ and Rolfe models separate these stages, John’s model merges them together and this can be confusing for inexperienced learners. Learning is the final stage in Johns’ model, a level that gives the author an insight idea of dealing with such problems. It is another strong point for this model because it stresses on what the individual learned from the incidence.

Rolfeâ??s reflection model

Rolfe’s model on practice is built on three main questions: what? So what? Now what? The first question, what addresses the problem and the events around it [7]. It also questions the rationale behind the event, the role of the author in that and even the specific actions that they undertook in the process. Unlike Gibbs’ model, it goes further to question the good and the bad activities during the incident like an evaluation. The second question questions the implications of the events as interpreted by the author. It addresses the basis of the author’s actions, possible skills to learn from the event, other possible solutions as well the new understanding of that case. These culminate to the final question that looks forward to better solutions. The weakness of this model comes from the shallow scrutiny that is given to the activities of the event. Just after the description is the quest for the alternatives measures, without giving the chance for a deeper self-examination, evaluation, and analysis.

Why Gibbsâ?? reflective mode

From the above divergent features of the three models, their levels of relevance to the described event can be determined. Reflection impacts effective solution after the individual under the case expresses a deeper feeling of disturbance from the problem. This idea is mentioned in the review of Jayatillake and Mackie [8] that addressed reflection as part of a continuous professional development. Taking a consideration of my case described above, it can be noted that the frustrations that I got from the encounter with the violent visitor aroused frustrations and anxieties in me that I kept reflecting on. This means that a proper intervention of this problem should largely consider the feelings that I experienced and the actions that aroused these feelings. Gibbs theory fits the above care better than the other two models in that, it dwells a lot on the feelings and analysis of the events at the scene. Such features make it a better choice for reflecting this case. To give more support Gibbs’ model, it gives a deeper evaluation and critique of the specific undertakings of the individual. Therefore, the Gibbs’ model becomes the method of making a more detailed reflection and self-examination of the past incidence. The section below gives an explicit reflection of the case in a step by step manner according to Gibbs model.

Reflection on the Incidence Basedon Gibbsâ?? Model

Feelings I felt very frustrated and upset since I couldn’t push the visitor back or defend myself on personal level. That being my first time to encounter such an incidence, I felt offended and mishandled by the visitor’s continued control on the patient despite my efforts to calm him. I also felt embarrassed by the idea that he continued to shout and push me right in the presence of the other nurses and my staff members. I also felt sad that the security team could not intervene even at such a stage. Even after the scene, I still felt the embarrassed when I thought about it. Nevertheless, I felt my action was not the best for the occurrence. Evaluation I left the scene with elevated feelings of discomfort and displease because I knew that I had not given a perfect approach to the situation. However, after gaining a calm state of mind and a careful examination of my response, I realized that such violence cases are common events in the healthcare environment that form an integral part of the practice [9]. Despite the negative feelings, I consoled myself with some positive initiatives that I undertook in solving this. What was good Despite the anger and frustrations, I managed to control my feelings and stress during and after the event. Such was important in keeping a peaceful work environment for the betterment of the patients and the other nurses. Besides, I managed to take the issue to the security and management teams who were in better position to devise the long-term solutions to such chaos. This is in line with the suggestions of Wei et al. [10] who mentioned that organizational characteristics and management styles also contribute to better means of handling hospitals violence among nurses. Another important step was to protect my colleagues from the assault and abuse by the visitor. It was good that I took the initiative of going to see what was happening and why all the shouting in the scene, otherwise, if had I opted to ignore, then more serious harm would have been done on the patient. Ignoring would have even lead to more harmful event to the other patients. Ignoring a case like that is what is referred by Rosenberg [11] as passive-aggressive behavior. In his article, this phenomenon is negatively characterized and cannot solve violence in the workplace. Therefore, it was important that we showed concern and unity as nurses and empathized with one another, as well as the patient. What was bad The negative occurrence in this event was my failure to make a quick decision and call the security team who displayed a weakness in controlling the visitors. Instead of requesting security to take the team to control the situation, they stood back and watched, waiting for their leader. The delayed intervention of the security team gave ways for the advancement of the event. It is also important to note that the chaos within the ICU poses more serious threats to patients

than in other clinical environments. However, such conflicts can be regarded as inevitable occurrences that can easily emerge whenever nurses are not given the intense training in violence management as recommended by Gerdtz et al. [12]. On the other hand, it was a revelation of the nurses’ vulnerability. Analysis That case was made more pronounced due to the antagonism that emanated from the opposite moves by the visitor and the nurses in an attempt to take a control over the patients. The state of the bed and the fallen nurse indicated that there was a physical struggle. This was more risky to the patient as she faced the opposing forces at her sickened state. Hartley et al. [13], presents a case whereby nurses should attend to an online program on how to handle the various cases of conflict within the healthcare facilities. Their study estimated the positive impacts of such online programs concluded that training boosts their psychological capabilities of examining patients and visitors. Therefore, I could have noticed or irresponsible behavior in the visitor from how his conversation before the case escalated to conflicts. Nevertheless, I realized that I was supposed to make a quick decision and seek the easily available solution such as calling the security team. For instance, in this incidence, I could have taken a short duration of time to call the security before hurrying to the scene. It was important to share the incidence with the security team leader immediately instead of waiting for the conference gathering. Dealing with the stressful moment as soon as they happen is recommended by many researcher of psychology including Sharma et al. [14]. Further, I could not have shown any form of anger or agitation on my face because it only made the visitor to be more violent. Maintaining a clam position would have been important in such situations. Self-control is one of the findings of Akbar et al. [15] in a qualitative study to determine how nurses cope with stressful moments. Action plan I have come to identify some of the ways that I can use to handle and contain such incidences when they arise in the future. I have realized the need to scrutinize an event even before involving the eternal efforts of other people. However, I have also realized the essence of seeking support, at the appropriate time when faced with such troubles. Therefore, after the deep scrutiny of my actions, I have settled on the idea of setting my personal action guidelines for approaching similar cases in the future. Moreover, I have made a guideline to follow daily in the morning to boost my resilience to set proper guidelines for dealing with the issue of verbal abuse that can come from the visitors. It gives me the emotional strength and the power to overcome any possible verbal abuse and other forms of abuse that can arouse stress. This also recommended by Sharma et al. [14]. Besides this is also a promising mechanism for handling violent individuals. The other important mechanism that I have put in place is training and extensive reading. Attending both the physical and online training that builds on my psychological comfort is another mechanism that I have scheduled for my programs. Training is also highly recommended by Akbar et al. [15] who examined the various means

of managing conflicts and stress at the workplace. Besides, Overton and Lowry [16] also stress that attending training sessions on how to identify potential crisis situations and the use of crisis-intervention techniques can be effective solutions. They indicate that “…training in conflict resolution skills can result in improved teamwork, productivity, and patient and employee satisfaction. Strategies to address a disruptive physician, a particularly difficult conflict situation in healthcare, are addressed” (p. 259). I have also appreciated the idea of supporting my colleagues within the facility. This comes from the view that I had on the nurse who had been thrown to the floor. Whenever such cases arise, then I will make sure to find all the means of providing support. However, it is also important to report the case to the management for additional input. I have also planned to seek mentorship from my senior employees and supervisors for additional advice in dealing with such cases in the future. This would assist me in improving the own strengths and enhance personal skills within the team. Having such skills would have helped me in calming the visitor to a considerable extent.

Conclusion

Conflicts and disagreements within the workplace are often inevitable. Such stipulation foreshadows the condition in the healthcare systems which are even more sophisticated due to the nature of the medication activities and the delicate patients involved. Conflicts and disagreements often arise from incoherent reasoning and opinions. Peoples’ opinions and thoughts have to vary at some time due to the diversity in human reasoning. Therefore, the only way to handle such differences is to harmonies them before chaos erupted. My case with the visitor in our facility gives a typical example of how people’s feelings and opinions can diverge and how reflection on practice can help on to learn. If I take a reflection of my case, I faced an opposing opinion that ended up breaking the peace within the hospital. Nevertheless, I have realized that I could have undertaken my activities differently after the scrutiny of my actions using the reflection models. Such models offer strong guidelines for examination of ones’ actions and for an improvement in the next instance. Moreover, Gibbs’ model has proven to be more strategic in solving conflict-related instances as seen in my case because of the deeper scrutiny and evaluation it has on actions and resultant feelings. From my case, I realized that it is important for me to have a written guideline on how to approach such cases. Having a selfdirecting plan would have provided me with a guideline on what to do in such cases. When such incidences are scrutinized alongside the various models of reflection on practice, then better mitigation measures may be attained for the future implications.

References

1. 1. AbuAlRub RF and Khawaldeh AT “Workplace Physical Violence among Hospital Nurses and Physicians in Underserved Areas in Jordan” J Clin Nurs 23 (2014): 1937-1947
2. 2. Sofield L and Salmond SW. “Workplace Violence. A Focus on  Verbal Abuse and Intent to Leave the Organization”. Orthop Nurs22 (2003):274–283
3. 3. Oelofsen N. “The Importance of Reflective Practices. Accessed From” (2012).
4. 4. Gibbs G. “Learning by Doing; A Guide to Teaching and Learning Methods. London: Further edu Unit. (1988).
5. 5. Jayatilleke N, and Mackie A. “Reflection as Part of Continuous Professional Development for Public Health Professionals: A Literature Review”. J Puc Health, 35(2013): 308 312.
6. 6. Barksby J, Butcher N, and Whysall A. “A New Model of Reflection for Clinical Practice”. Nurs times. 111(2015): 21-23.
7. 7. Smith K. “Reflection and Person-Centredness in Practice Development. International Practice Development” J 6(2016).
8. 8. Jayatillake N, and Mackie A. “Reflection as Part of Continuous Professional Development for Public Health Professionals: A Literature Review”. J puc health, 35 (2013): 308 312.
9. 9. Ramacciati N, and Ceccagnoli A, Addey B, Lumini E,et al. “Interventions toRisk of Violence Toward Emergency Department Staff: Current Approaches”. Open Access Emergency Medicine, 8(2016):17–27
10. 10. Wei C, Chiou S, and Chien L. “Nicole Huang Workplace Violence Against Nurses – Prevalence and Association with Hospital Organizational Characteristics and Health-Promotion Efforts: Cross- Sectional Study”. International J Nurs Studs, 56(2016):63– 70
11. 11. Rosenberg D, “Tips for Solving Workplace Violence: Managing Rage.” (2011).
12. 12. Gerdtz MF, Daniel C, Dearie V, Prematunga R, Bamert M, and Duxbury J. “The Outcome of a Rapid Training Program on Nurses’ Attitudes Regarding the Prevention of Aggression in Emergency Departments: a Multi-Site Evaluation”. International J Nurs Studs,
13. 50 (2013): 1434–1445.
14. 13. Hartleya M, Ridenoura M, Craineb J, and Allison Morrill“Workplace Violence Prevention for Nurses On-Line Course”. ProDevelopment Work 51 (2015): 79–89.
15. 14. Sharma P, Davay A,Davey J, Shukla A, et al. “Occupational StressAmong Stress Nurses: Controlling the Risk to Health”. Indian JOccupational and Environmental Medicine, 3(2016): 89-94
16. 15. Akbar RE, Elahi N, Mohammadi E, and Khoshknab MF. “What Strategies Do the Nurses Apply to Cope With Job Stress?: A Qualitative Study”. Glob J Health Sci, 8 (2016): 55-65.
17. 16. Overton AR, and Lowry AC. “Conflict Management: Difficult Conversations with Difficult People”. Clinical Colon and Rectal Surgery, 26(2013): 259-264